ASN Wikibase Occurrence # 58497
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| Date: | Wednesday 14 September 2005 |
| Time: | 07:20 |
| Type: |  ATR 42-320 |
| Owner/operator: | Coast Air |
| Registration: | LN-FAO |
| MSN: | 148 |
| Year of manufacture: | 1989 |
| Fatalities: | Fatalities: 0 / Occupants: 27 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Southeast of the glacier Folgefonna -
 Norway
|
| Phase: | En route |
| Nature: | Passenger - Scheduled |
| Departure airport: | Stord-Sørstokken Airport |
| Oslo-Gardermoen Airport | |
| Investigating agency: | AIBN |
| Confidence Rating: |  Accident investigation report completed and information captured |
Coast Air's flight 602 from Stord Airport Sørstokken to Oslo Airport Gardermoen had 24 passengers and a crew of 3 on board when it took off on the morning of 14 September 2005. A cold front had passed over the coast and was on its way east, and local moderate icing was forecast.
While climbing, when passing flight level FL100 (approx. 10,000 ft), ice began to form on the aircraft. The aircraft's de-icing systems were switched on and functioned normally. Nevertheless, more ice built up and, when passing through FL120, there was a marked reduction in the aircraft's climb ability. At FL140 the autopilot disconnected, at much the same time as the aircraft entered an uncommanded roll to approx. 45 degrees to the right and began to lose height. When the crew believed they had regained control, the aircraft suddenly rolled uncommanded to the left in a similar manner. Around one and a half minutes after the first uncommanded roll movement, the climb was stable once more. The flight continued to Gardermoen without any further problems. The loss of altitude in the incident was approx. 1500 ft, and was
not critical in relation to terrain height. No personal injuries or material damage occurred.
In addition to establishing how and why the control of the aircraft was temporarily lost, the AIBN has uncovered several latent contributing factors and safety problems in this investigation. These safety problems can roughly be subdivided into four groups:
- Operation of this aircraft type in icing conditions
- Serious deficiencies in the company's quality system and flight safety programme
- Insufficient follow-up and rule enforcement on the part of the CAA-N after it had disclosed serious deficiencies in the quality system and flight safety programme in its flight operations inspections of the company over several years prior to the incident.
- The company was assigned two new tendered routes despite the deficiencies in its safety management persisting.
In the opinion of the AIBN, this case illustrates the importance well functioning safety regulation has on aviation safety. The failure of the CAA-N follow-up contributed to deficiencies in the Coast
Air quality system and flight safety programme not being corrected in time.
Accident investigation:
 |
|
Sources:
http://www.aibn.no/items/3216/144/8519822396/LN-FAO%20Eng..pdf
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 17-Jan-2009 02:59 | harro | Added |
Corrections or additions? ... Edit this accident description
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